Topmed Comprehensive medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply. Pay for all children.

View all plans in this scheme

IN HOSPITAL PROCEDURES:

Payout Rate for Specialists:

300% scheme rate

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

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Topmed Executive 2017

Hospital Choice:

Unlimited

Specialised Radiology:

R2,500 co-payment per scan

Supplementary Services: (Physio, etc)

100% scheme rate
Stomatherapy: R18,900 per family

Transplants:

Covered

Co-payments:

Gastroscopies and colonoscopies: R2,500
Specialised radiology: R2,500 per scan
Dentistry (in-hospital): R1,600
Impacted wisdom teeth: R1,060

Alternatives to hospitals:

Private nursing and step down facilities and hospice: R131,676 per person

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OUT OF HOSPITAL BENEFITS:

GP consultations:

Paid from day-to-day benefit, at 80% scheme rate when from above threshold benefit

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

Specialists consultations:

Paid from day-to-day benefit, at 80% scheme rate when from above threshold benefit

Pathology:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

General radiology:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

Specialised radiology:

R2,500 co-payment per scan

Supplementary Services: (Physio, etc)

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

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MATERNITY BENEFITS:

Hospital stay:

300% scheme rate
Home births: covered

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

Consultations:

12 consults
12 ante natal classes
Pre-natal vitamins
2 paediatrician visits (newborn)
Paid by scheme

Scans:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

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CANCER (ONCOLOGY):

Overall coverage (in and out of hospital):

R564,444 per person, with 20% co-payment thereafter
Biological medicine: R319,500 per family, part of the above limit
Herceptin: no co-payment for 9 week course

Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

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DENTISTRY:

Dentistry:

Standard and specialised dentistry: R22,776From day-to-day benefit, with 80% scheme rate when from above threshold benefit
In hospital: for kids under 6yrs and dental clearance R1,600 co-payment
In hospital impacted wisdom teeth: R1,060 co-payment
Orthognathic surgery: 20% co-payment

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

Orthodontics:

Orthodontics: fixed braces for under 18yrs, one family member at a time

Maxillo Facial Surgery:

300% scheme rate, limited to severe trauma or facial deformity

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MEDICATION:

Chronic:

PMBs chronic: covered
non-PMBs:
Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

Acute (presrcibed) medication:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

Over-the-counter:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
Vitamins and Minerals: M= R2,460, Adult= R2,028 and child=R564

Birth Control:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

On Discharge:

7 days supply

Notes:

For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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OPTOMETRY:

Optometry:

Paid from day-to-day benefit, at set rates when from above threshold
Contact lenses: R2,292 per person

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

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MENTAL HEALTH:

In-hospital:

21 days per person

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

Out-of-hospital:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

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OTHER BENEFITS:

General Appliances:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

1.1. Hearing Aids:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

1.2. Wheelchairs:

Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

Dialysis:

Covered

HIV:

Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols

Emergency Transport:

ER24

International Coverage:

R10 million per family per year, maximum of 90 days

Other:

Post-operative benefits hip and knee replacement (trauma only), heart attack, post crime trauma, stroke

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WELLNESS/PREVENTATIVE BENEFITS:

Flu vaccination:

Covered

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

Pneumonia vaccines:

Covered

Back Rehabilitation Programme:

Biometric Screening:

Covered

Child Immunisation:

Covered

Pap Smear:

Covered

Mammogram:

Covered for 40yrs+, every 2 years. Includes sonar.

PAS Test:

Covered, 40yrs+. Frequency dependant on age.

HIV Test:

Covered, 15yrs+

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PROSTHESIS:

Overal Limit:

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Total Cost:	R6,070	R5,010	R1,425
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Executive 2017

Sub-limits:

Important!

Unless specified, assume that all benefits are paid are paid at 100% scheme rate
No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
“Unlimited” benefits are still subject to authorisation, protocols and sublimits
Assume that all benefits need to be pre-authorised